How Did The Health Care Mandate Get Here?

March 31, 2012

All this week, we heard about the Supreme Court arguments on the Affordable Care Act – also known as President Obama’s health care law.

Over the three days, several key aspects of the law were examined including the expansion of Medicaid and whether the Supreme Court actually had the right to hear the case right now. But the core of the case mounted against Obama’s health law hinges upon the individual mandate, the part that will require almost every American to have or to buy health insurance.

The idea of the individual mandate to control health care costs, however, is not new. In fact it goes back to 1989, to a man named Mark Pauly. An expert on health care policy, Pauly was a part of the group of academics brought to the White House by President George H.W. Bush.

The group’s task was to fix health care, and their solution was to let the marketplace solve it and create an individual mandate. Pauly tells weekends on All Things Considered host Guy Raz that, at the time, many Republicans, including the president, loved it.

“Legislation was drafted, but never made it as a bill because the word from the Democrats in Congress was [that] it would be dead on arrival,” Pauly says.

Pauly believes the reason the individual mandate is front and center in this debate is because it is an objection that can be cast in the form of a constitutional challenge, unlike other parts of the bill.

“To some extent I’m a little surprised that this feature [that] we thought as kind of an afterthought has become so prominent,” he says. “The current individual mandate, in my view, is kind of a puny thing because the penalties are relatively small.”

In contrast, under the mandate Pauly’s group proposed, failure to secure health insurance would result in a penalty equal to the premium for the cheapest qualified health coverage. You would also automatically be assigned to a fallback insurer that the government would contract with, Pauly says.

“We though then, and I think now, that it would be good to have a society in which everybody has at least some basic catastrophic insurance,” he says.

Though he says what’s being mandated in the current legislation is much more elaborate than what his group had in mind, Pauly says it’s “better than nothing, and we could work with it to fix it up.”

More Than Just The Mandate

While Mark Pauly’s plan may have been dead on arrival in 1989, it did eventually make it to the Senate floor in the form of a bill. It was an idea proposed by Republicans as an alternative to President Bill Clinton’s health care initiative in 1993.

At the time, then newly-elected Sen. Bob Bennett, a Republican from Utah, and about 20 other Republicans set out to offer an alternative plan to what they disparagingly called “Hillarycare,” after then first lady Hillary Clinton who wrote the White House plan.

The individual mandate was a part of their plan and it was even supported by the Republican leader Bob Dole. Back then, just two Democrats backed it.

Bennett tells NPR’s Raz that the objection to the individual mandate did not arise until after Obamacare was written.

“Nobody was talking about it during the debate [in 1993],” Bennett says.

Though he helped create a plan that included an individual mandate, Bennett opposed the current legislation and voted against it. He says there are many more problems with the bill, but that the individual mandate has emerged as the “litmus test” for whether or not it is good legislation.

“I’m not opposed to the individual mandate but I still think the bill is a terrible piece of legislation,” he says. “The accounting simply does not add up.”

Sen. Harry Reid was under pressure from the White House to pass the bill, Bennett says, regardless of what it said. Looking at the details of the bill, he says it would have a devastating effect on states and Medicare — among other problems.

“Frankly, I never even thought about the individual mandate as I voted against [the bill],” he says.

For Reid Cherlin, this past week was a dose of déjà vu. Cherlin was President Obama’s chief spokesman on health care until March of last year. He didn’t have to defend the law in front of the Supreme Court, but he tells Raz that doesn’t mean his job was any easier.

“Answering questions about the bill, no matter what the questions are, is extremely difficult because it is so complicated,” Cherlin says.

Cherlin says the problem is that the relationship between the American people and their health care coverage is tricky. He says the public generally don’t like the system, are skeptical of the players and they’d rather not have to deal with it than have anything change.

“And the minute you say ‘under Obamacare you’d have to do X, Y and Z,’ no one wants to do anything with their health care,” he says. “They just want it to be there and not get sick.”

A couple of days ago, in a blog post for GQ Magazine, Cherlin posted some of the quotes he gave reporters about the law. He called them “torturous and horrible,” including this one:

“The president has made it clear that health insurance reform legislation should prevent insurance companies from placing annual limits on health expenditures that can force families into financial ruin. We will continue to work with Congress on this policy.”

It was that kind of language that made it so hard to make the case for the Obama plan, Cherlin says. In hindsight, he says the White House didn’t do itself any favors.

“There are a lot of good things that it does, but for a bumper sticker or a 15-second blurb, basically you’ve got to pick one,” he says. “There was a lot of disagreement … so consequently, we were talking about different things at different times.”

And with all of those different messages floating around, Cherlin says that might be why nothing seems to have stuck.

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